ASUHAN KEBIDANAN PEREMPUAN DAN ANAK

PADA MASA RENTAN

“KEBUTUHAN PERMASALAHAN GEOGRAFIS”

Diajukkan Untuk Memenuhi Salah Satu Tugas Mata Kuliah

Sarjana Kebidanan Alih Jenjang

SUCI NURJANAH
FE23011

SARJANA KEBIDANAN ALIH JENJANG

INSTITUT KESEHATAN RAJAWALI
2023
REVIEW JURNAL

A. Permasalahan
Penelitian ini mengkaji hubungan akses terhadap air bersih dan fasilitas sanitasi di
tingkat rumah tangga dan masyarakat dengan prevalensi diare pada anak balita di Indonesia.
Studi ini menganalisis data dari Survei Demografi dan Kesehatan Indonesia tahun 2007 dan
2012. Di tingkat rumah tangga, akses terhadap air pipa dikaitkan dengan rendahnya prevalensi
diare pada anak-anak, sementara peningkatan fasilitas sanitasi dan pengolahan air tidak
menunjukkan dampak signifikan secara langsung. Di tingkat masyarakat, peningkatan cakupan
sanitasi yang baik dikaitkan dengan penurunan prevalensi diare pada anak-anak. Studi ini juga
mengeksplorasi interaksi antara air, sanitasi dan faktor risiko lainnya, dan menemukan 10
istilah interaksi yang signifikan. Penelitian ini menemukan bahwa perbaikan akses terhadap air
dan sanitasi merupakan hal yang paling efektif dalam mengurangi risiko diare pada anak.
Diare merupakan masalah kesehatan yang penting di negara-negara berpenghasilan
rendah dan menengah, termasuk Indonesia. Indonesia sangat mencerminkan pola global ini.
Sebagian besar (18%) rumah tangga di Indonesia mengandalkan air minum mereka dari sumber
air permukaan, seperti mata air, sungai, kolam dan danau, yang rentan terhadap masalah
kontaminasi (Badan Pusat Statistik, 2014). Selain itu, Indonesia memiliki jumlah penduduk
tertinggi kedua di dunia yang melakukan buang air besar sembarangan (UNICEF & WHO,
2015). Hal ini semakin meningkatkan resiko pencemaran lingkungan dan pencemaran air.
Ketika kualitas persediaan air kurang idela, pengolahan air dengan merebus,
mengklorinasi, menyaring atau metode lainnya merupakan strategi perilaku yang penting untuk
mengurangi resiko diare. Pengolahan air di tempat penggunaan meningkatkan keamanan
mikroba air sebelum dikonsumsi dan mengurangi resiko penyakit diare, khususnya di negara
berkembang.
Hasilnya kesehatan anak-anak di rumah tangga dengan air dan sanitasi yang baik
mungkin menjadi kurang optimal jika tingkat kebersihan lingkungan tempat tinggal rumah
tangga tersebut rendah. Kebersihan lingkungan yang buruk dapat secara langsung (misalnya
melalui kontak dengan air yang terkontaminasi atau kotoran manusia di lapangan terbuka) atau
secara tidak langsung (misalnya melalui kontak dengan lalat atau anak-anak lain yang
terkontaminasi) menyebarkan kontaminasi feses dan kontaminasi air ke masyarakat. Dengan
cara ini, anggota rumah tangga yang sudah memiliki air dan sanitasi yang baik mungkin akan
terkena dampaknya. Oleh karena itu, dampak limpahan yang penting antara faktor-faktor di
tingkat rumah tangga dan masyarakat dapat menjadi relevan.
 Pada tingkat individu, usia dan jenis kelamin anak merupakan hal yang penting. Sekitar
80% dari total kejadian diare terjadi pada anak-anak di bawah usia dua tahun . Setelah usia ini,
tingkat penyakit menurun karena infeksi pertama menyebabkan tingkat kekebalan tertentu,
yang melindungi terhadap kejadian berikutnya. Gender juga penting karena adanya perbedaan
fungsi sistem imun antara anak perempuan dan anak laki-laki, dan karena anak perempuan
terbukti memiliki tingkat morbiditas dan mortalitas yang lebih rendah dibandingkan anak laki-
laki.
Diare merupakan masalah kesehatan yang penting di Indonesia dan juga di banyak
negara berkembang lainnya. Studi ini menemukan bahwa air pipa di rumah mengurangi risiko
diare pada anak kecil, sedangkan pengolahan air bersih dan perbaikan toilet tampaknya tidak
mempunyai pengaruh langsung yang signifikan.

B. Penanganan
Penyakit diare di Indonesia merupakan salah satu masalah kesehatan masyarakat yang
utama. Hal ini disebabkan karena masih tingginya angka kesakitan diare yang menimbulkan
banyak kematian terutama pada balita, karena balita sangat rentan terhadap penyakit diare. Hal
yang menyebabkan seseorang mudah terserang penyakit diare pada balita adalah perilaku hidup
masyarakat yang kurang baik dan sanitasi lingkungan yang buruk. Diare dapat berakibat fatal
apabila tidak ditangani secara serius karena tubuh balita sebagian besar terdiri dari air dan
daging, sehingga bila terjadi diare sangat mudah terkena dehidrasi. Keadaan sanitasi
lingkungan yang paling dominan yaitu sarana penyediaan air bersih dan pembuangan tinja,
kedua sarana ini akan berinteraksi bersama dengan perilaku manusia.
Ada beberapa penyebab yang berkaitan dengan kejadian daire yaitu tidak memadainya
penyediaan air bersih, air tercemar oleh tinja, kekurangan sarana kebersihan, pembuangan tinja
yang tidak higenis, kebersihan perorangan dan lingkungan yang jelek, serta penyiapan dan
penyimpanan makanan yang tidak semestinya (Sander, 2005).
Risiko yang sangat berpengaruh untuk terjadinya diare pada balita, yaitu status
kesehatan lingkungan (penggunaan sarana air bersih, jamban keluarga, pembuangan sampah,
pembuangan air limbah) dan perilaku hidup sehat dalam keluarga. Sedangkan secara klinis
penyebab diare dapat dikelompokkan dalam enam kelompok besar yaitu infeksi (yang
meliputi infeksi bakteri, virus, parasit, malabsorbsi, allergi, keracunan bahan-bahan kimia,
keracunan oleh racun yang dikandung dan diproduksi baik jazad renik, ikan, buah- buahan,
sayur-sayuran, (algae), imunisasi, defisiensi, dan sebab-sebab lain.
 Menurut Widjaja dalam Zubir dan Wibowo (2006), diare diartikan sebagai buang air
encer lebih dari empat kali sehari, baik disertai lendir dan darah maupun tidak. Hingga kini
diare masih menjadi child killer (pembunuh anak-anak) peringkat pertama di Indonesia.
Menurut Putri Yundari (2012), sumber air minum tidak terlindung seperti sumur, harus
memenuhi syarat kesehatan sebagai air bagi rumah tangga, maka air harus dilindungi dari
pencemaran. Sumur yang baik harus memenuhi syarat kesehatan antara lain, jarak sumur
dengan lubang kakus, jarak sumur dengan lubang galian sampah, saluran pembuangan air
limbah, serta sumber-sumber pengotor lainnya. Jarak sumur dengan tempat pembuangan tinja
lebih baik 10 meter atau lebih Sumber air minum merupakan salah satu sarana sanitasi penting
berkaitan dengan kejadian diare. Menurut Depkes RI (1994) menunjukkan bahwa
menggunakan sarana air bersih yang tidak memenuhi syarat sanitasi akan meningkatkan risiko
terjadinya diare berdarah pada anak balita sebesar 2,47 kali dibandingkan keluarga yang
mengunakan sarana air bersih yang memenuhi syarat sanitasi.
Kejadian diare bukan hanya di akibatkan oleh keadaan sanitasi sarana air bersih tetapi
ada penyebab lain kejadian diare yaitu :
1. Usia
Semakin muda umur balita semakin besar kemungkinan terkena diare, karena
semakin muda umur balita keadaan integritas mukosa 37 usus masih belum baik,
sehingga daya tahan tubuh masih belum sempurna. Kejadian diare terbanyak menyerang
anak usia 7-24 bulan, hal ini terjadi karena:
a. Bayi usia 7 bulan ini mendapat makanan tambahan diluar ASI dimana risiko
ikutsertanya kuman pada makanan tambahan adalah tinggi (terutama jika
sterilisasinya kurang)
b. Produksi ASI mulai berkurang, yang berarti juga anti bodi yang masuk bersama ASI
berkurang
c. Setelah usia 24 bulan tubuh anak mulai membentuk sendiri anti bodi dalam jumlah
cukup (untuk defence mechanism), sehingga serangan virus berkurang.
2. Status gizi
Pada penderita kurang gizi diare lebih sering terjadi. Semakin buruk keadaan gizi
anak, semakin sering dan berat diare yang diderita. Diduga bahwa mukosa penderita
malnutrisi sangat peka terhadap infeksi karena daya tahan tubuh yang kurang. Faktor
susunan makanan berpengaruh terhadap terjadinya diare disebabkan karena kemampuan
usus untuk menghadapi kendala, baik itu yang berupa;
a. Susunan makanan mengandung protein yang tidak homolog sehingga dapat berlaku
 sebagai antigen. Lebih - lebih pada bayi dimana kondisi ketahanan lokal usus belum
sempurna sehingga terjadi migrasi molekul makro
b. Susunan makanan baik berupa formula susu maupun makanan padat yang
memberikan osmolaritas yang tinggi sehingga dapat menimbulkan diare
c. Kandungan nutrient makanan yang berupa karbohidrat, lemak maupun protein
dapat menimbulkan intoleransi, malabsorpsi maupun alergi sehingga terjadi
diare pada balita
d. Kandungan serat yang berlebihan dalam susunan makanan secara mekanik dapat
merusak fungsi usus sehingga timbul diare
 REFFERENSI

Ahmad Komarulzaman, Jeroen Smits & Eelke de Jong (2017) Clean water, sanitation and
diarrhoea in Indonesia: Effects of household and community factors, Global Public
Health, 12:9, 1141-1155, DOI: 10.1080/17441692.2015.1127985
Canda, dkk. 2013. Hubungan Antara Keadaan Sanitasi Sarana Air Bersih Dengan Kejadian
Diare Pada Balita. Poltekes Denpasar Jurusan Kesehatan Lingkungan. Jurnal Kesehatan
Lingkungan Vol. 4 no 1, Mei 2014 : 112 – 117. [Link]
[Link]/files/JURNAL%20KESEHATAN%20LINGKUNGAN/Yennie%20Candra1,
%20M%20Choirul%20Hadi2,%20Anysiah%20Elly%[Link] (diakses pada 15
Desember 2023)
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Clean water, sanitation and diarrhoea in

Indonesia: Effects of household and community
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Ahmad Komarulzaman, Jeroen Smits & Eelke de Jong

To cite this article: Ahmad Komarulzaman, Jeroen Smits & Eelke de Jong (2017) Clean water,
sanitation and diarrhoea in Indonesia: Effects of household and community factors, Global
Public Health, 12:9, 1141-1155, DOI: 10.1080/17441692.2015.1127985

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GLOBAL PUBLIC HEALTH, 2017
VOL. 12, NO. 9, 1141–1155
[Link]

Clean water, sanitation and diarrhoea in Indonesia: Effects of

household and community factors
Ahmad Komarulzamana,b, Jeroen Smitsb and Eelke de Jongb
a
Department of Economics, Faculty of Economics & Business, Universitas Padjadjaran, Bandung, Indonesia;
b
Radboud University Nijmegen, Institute for Management Research, Nijmegen, The Netherlands

ABSTRACT ARTICLE HISTORY

Diarrhoea is an important health issue in low- and middle-income Received 20 January 2015
countries, including Indonesia. We applied a multilevel regression Accepted 2 November 2015
analysis on the Indonesian Demographic and Health Survey to
KEYWORDS
examine the effects of drinking water and sanitation facilities at Diarrhoea; drinking water;
the household and community level on diarrhoea prevalence sanitation; multilevel
among children under five (n = 33,339). The role of the analysis; Indonesia
circumstances was explored by studying interactions between the
water and sanitation variables and other risk factors. Diarrhoea
prevalence was reported by 4820 (14.4%) children, who on
average were younger, poorer and were living in a poorer
environment. At the household level, piped water was
significantly associated with diarrhoea prevalence (OR = 0.797,
95% CI: 0.692–0.918), improved sanitation had no direct effect
(OR = 0.992, 95% CI: 0.899–1.096) and water treatment was not
related to diarrhoea incidence (OR = 1.106, 95% CI: 0.994–1.232).
At the community level, improved water coverage had no direct
effect (OR = 1.002, 95% CI: 0.950–1.057) but improved sanitation
coverage was associated with lower diarrhoea prevalence (OR =
0.917, 95% CI: 0.843–0.998). Our interaction analysis showed that
the protective effects of better sanitation at the community level
were increased by better drinking water at the community level.
This illustrates the importance of improving both drinking water
and sanitation simultaneously.

Introduction
The latest UNICEF & WHO (2015) report on sanitation and drinking water worldwide
indicates that over 663 million individuals still lack access to safe drinking water and
159 million persons rely on surface water for their water consumption. Within countries,
the regional disparity in water access is substantial. About 79% of people depending on
unimproved drinking water and 93% depending on surface water live in rural areas
(UNICEF & WHO, 2015). In addition, 2.4 billion people (32%) worldwide lack access
to improved sanitation facilities. In these situations, with poor water quality and high con-
tamination risk, diseases such as diarrhoea become a major concern. Diarrhoea is still one
of the most important killers of children under five (WHO & UNICEF, 2013a).

CONTACT Ahmad Komarulzaman [Link]@[Link]

© 2016 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License
([Link] which permits non-commercial re-use, distribution, and reproduction in any
medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
1142 A. KOMARULZAMAN ET AL.

Indonesia closely reflects this global pattern. A considerable proportion (18%) of Indo-
nesian households rely for their drinking water on surface water sources, such as springs,
rivers, ponds and lakes, which are prone to contamination problems (Statistics Indonesia,
2014). Only 11% of Indonesian households have access to piped water inside their dwell-
ing (Statistics Indonesia, 2014), and even then the quality is often below the minimum
requirement for drinking water, with fluctuating debit and frequent interruptions
(Surjadi, 2003). Sometimes the piped water is contaminated with faecal coliform and
unsafe to be consumed without processing steps (Bakker, 2007). Almost all households
boil their drinking water (Prihartono et al., 1994), but this is not always done effectively,
as 55% of drinking water samples were found to be contaminated with faecal coliform
(Vollaard et al., 2004).
In addition, Indonesia has the second highest number of people (54 million) in the
world that practice open defaecation (UNICEF & WHO, 2015). This increases the risk
of environmental pollution and water contamination even more. Given the poor quality
of water and sanitation, it comes as no surprise that diarrhoea is still a major health
concern in Indonesia, responsible for 31% of post-neonatal mortality and 25% of child
mortality (UNICEF, 2012).
Whether a child suffers from diarrhoea is influenced by many factors, at the level of the
household as well as at the level of the community in which the household is living. Ideally,
an analysis of the determinants of diarrhoea should take all relevant factors at both levels
into account (Corsi et al., 2011; Fewtrell et al., 2005). Children from a household with good
quality water and sanitation are still at risk for diarrhoea if they live in a community with
open defaecation, due to the contamination of soil and water sources (Andres, Briceño,
Chase, & Echenique, 2014; Corsi et al., 2011). By focusing the analysis only on factors
at the household level, an incomplete picture is obtained and interventions might
appear to be less effective than they truly are (Corsi et al., 2011).
From a policy perspective, it is very important to know whether the effects of risk
factors vary across circumstances. If it is known under which circumstances a certain
risk factor or protective measure is important, policy-makers can tailor interventions
towards the requirements of the specific situation. We can find these circumstances by
including interaction terms between the risk factor or protective measure and variables
indicating the circumstances in our analysis. However, until now no encompassing
study on diarrhoeal disease in Indonesia has been published in which both direct and
interaction effects of the major risk factors are studied simultaneously.
The current study aims to fill this gap in our knowledge by examining the impact on
childhood diarrhoea of the quality of water and sanitation at household and community
level in Indonesia. The model includes interactions between the risk factors and variables
describing the specific situation. We perform a multilevel analysis on data from the 2007
and 2012 Demographic and Health Surveys (DHS) in order to answer the following
research questions:

(1) Does access to and treatment of water and sanitation at the household level influence
diarrhoea prevalence?
(2) Does water and sanitation coverage at the community level influence diarrhoea
prevalence?
 GLOBAL PUBLIC HEALTH 1143

(3) Under what circumstances are water access and sanitation important for preventing
diarrhoea?

We expect that better quality of water and sanitation protect children against diarrhoea
and that the relevant factors are found at both the household and community level. In
addition, we expect that larger effects will be observed for children living in more deprived
circumstances, such as in poor households and in communities with poor hygiene.

Conceptual framework
Our theoretical framework assumes children’s health condition to be influenced by indi-
vidual, household and community factors (Figure 1). At the household level, we focus on
access to drinking water, on whether the water is treated, and on the quality of the sani-
tation facilities (arrow A in Figure 1). In Indonesia, many households still rely on unsafe
drinking water, such as water from unprotected wells and rivers that are vulnerable to
microbial contamination. This contamination takes place not only at the water source,
but also during collection, transport, storage, and serving of the water, due to faecally con-
taminated hands, utensils and insects (Shaheed, Orgill, Montgomery, Jeuland, & Brown,
2014).
Piped water on the premises is expected to be less contaminated, as by the nature of its
construction the piped water system protects against outside influences (WHO &
UNICEF, 2013b). In addition, households connected to piped water can improve their
health outcomes because more water is available for cleaning the house, thus facilitating
a better hygienic situation (Fewtrell et al., 2005). Connection to piped water does not,
however, always guarantee better water quality, as in less developed regions the water is
often not continuously running. This means that households still have to store water in
the home that is then vulnerable to (re)contamination (Fewtrell et al., 2005; Shaheed
et al., 2014; Wright, Gundry, & Conroy, 2004).
When the quality of the available water supply is less than ideal, treating the water by
boiling, chlorinating, filtering or other methods is an important behavioural strategy for
reducing the risk of diarrhoea (Clasen, Schmidt, Rabie, Roberts, & Cairncross, 2007).
Point-of-use water treatment improves the microbial safety of the water before consump-
tion (Sodha et al., 2011) and reduces the risk of diarrhoeal diseases, specifically in

Figure 1. The impact of the household and community level of water and sanitation on childhood
diarrhoea.
1144 A. KOMARULZAMAN ET AL.

developing countries (Fiebelkorn et al., 2012). However, the benefits of this treatment are
not guaranteed, as the cleanliness of the treated water is often not maintained during
storing and serving. It might for instance be touched while being put in or removed
from the containers, which reduces the protective effects of treatment (Sodha et al.,
2011; Wright et al., 2004).
Besides clean water, a good sanitation facility is protective against diarrhoea. Such a
facility separates the human excreta from direct contact with humans and ensures a
safe disposal of the faeces, thus reducing the risk of faecal contamination (Andres et al.,
2014). However, as shown by a recent cluster-randomised trial in rural Odisha, India,
proper sanitation facilities at the household level do not always improve health (Clasen
et al., 2014). Exposure to faecal contamination in the community can wipe out the ben-
eficial effects of good facilities at home.
Arrow B in Figure 1 highlights the importance of water and sanitation at the commu-
nity level for children’s health status. Health outcomes of children in households with
good water and sanitation might be suboptimal when the hygiene level of the environment
in which the household resides is low. Poor environmental hygiene may directly (e.g. by
contact with contaminated water or human excreta in the open field) or indirectly (e.g.
through contact with contaminated flies or other children) spread faecal contamination
and water contamination over the community. In this way, members of households
that already have good water and sanitation may be affected (Corsi et al., 2011; Gragnolati,
1999). Hence, important spillover effects between factors at the household and at the com-
munity level can be relevant.
Positive spillover effects may occur if households with access to clean water share their
water with neighbours that have no such access (Alderman, Hentschel, & Sabates, 2003).
This might facilitate better hygiene and health outcomes for children in the community
(Corsi et al., 2011; Gragnolati, 1999). An even stronger spillover effect is expected with
respect to the coverage of proper sanitation in the community (Alderman et al., 2003).
Although an improved toilet increases the hygiene level of the owner, it cannot fully elim-
inate faecal contamination from the neighbourhood if other households lack such a facility
(Andres et al., 2014; Clasen et al., 2014).
Indirect effects at the community level might also be important. Hughes and Dunleavy
(2000, as cited in Alderman et al., 2003), for example, found that positive health effects of
community access to water only materialised when combined with the community access
to toilet. We therefore include in our model interaction terms between the water and sani-
tation variables at household and community level (arrows C in Figure 1).

Control factors
Our model contains a number of control factors that are known or expected to influence
diarrhoea risk (arrows D in Figure 1). At the individual level, the child’s age and sex are
important. Approximately, 80% of the total diarrhoea incidence relates to children
younger than two years of age (Walker et al., 2013). After this age, the rate of illness
falls as the first infections induce a certain level of immunity, which protects against fol-
lowing incidences (Yu et al., 2015). Gender is also important, because of differences in
immune system functioning between girls and boys, and because girls have been shown
to have lower morbidity and mortality rates than boys (Muenchhoff & Goulder, 2014).
 GLOBAL PUBLIC HEALTH 1145

At the household level, we include mother’s education and household wealth. An edu-
cated mother may have a higher level of awareness about hygiene (Alderman et al., 2003)
and be better able to obtain clean water and to treat water effectively (Mangyo, 2008).
Poorer households have fewer resources to fulfil their basic necessities, have poorer
living conditions and have a lower health status, all factors that increase diarrhoea risk
(Hatt & Waters, 2006).
Control factors at community level are availability of health facilities, level of regional
development, urbanisation, adult education and the position of women in the area. House-
holds in more developed or urban regions can generally benefit from better infrastructure,
including more and better health facilities. Living under better circumstances in terms of
infrastructure and health services may benefit the households in the area, including their
children (Fotso & Kuate-Defo, 2005). Given that women are the major caretakers of young
children, a stronger position of women in the household and local community might be
favourable for children’s health. We therefore also control for the decision-making
power of women.

Methods
Data
This study utilised the Indonesia DHS from 2007 and 2012 (Statistics Indonesia & Macro
International, 2008; Statistics Indonesia, NPaFPBB, MOH, & ICF International, 2013).
These DHS surveys were designed to be representative at the national, urban, rural, as
well as provincial level. Both data sets collected information on demographic, socioeco-
nomic and health-related issues. To ensure the protection of human subjects, all DHS pro-
tocols are reviewed by an ethics review panel or institutional review board in the country
where the survey is conducted (ICF International, 2012).
For the current study, the surveys were pooled into a single data set. This combined
data set includes data on 33,399 children under age 5, from 28,573 mothers, living in
3069 sub-districts, within 922 districts, within 33 provinces. We excluded children with
missing data on diarrhoea infection (N = 338) and children with missing response(s) on
explanatory variable(s) (N = 1521 or an additional 4.4% of children).

Outcome variable
The outcome variable is a dummy variable indicating whether or not the child suffered
(yes = 1, no = 0) from diarrhoea in the past two weeks. This question was asked of all
mothers with living children under age five.

Independent variables
Independent variables were included at the household and sub-district level. A sub-district
is the second lowest pubic administration before village level. On average, it covers an area
of 273.6 km2 and has a population of about 36,000. Variables at sub-district level were
aggregated from household data. They were calculated as the proportion of individuals
or the mean of the variable within each sub-district.
1146 A. KOMARULZAMAN ET AL.

The main household level predictors were variables indicating whether there was piped
water in the dwelling (yes, no), whether point-of-use water treatment was used (yes, no),
and whether the household had improved sanitation (yes, no). Point-of-use water treat-
ment indicated whether the household used any treatment method, such as boiling,
bleaching, chlorinating, filtering or solar disinfection to the water before its consumption.
Improved sanitation indicated a toilet facility that ensured the separation of human
excreta from human contact, such as a toilet with septic tank, pit latrine or composting
toilet (UNICEF & WHO, 2015).
Other control variables were the child’s gender (girl, boy), age (0–4 years) and age-
squared, mother’s education (years of schooling completed), household wealth and
dummy variables indicating whether the household lived in an urban (1) or rural (0)
area and whether the household was interviewed in the 2007 (0) or 2012 (1) DHS
survey. Household wealth was measured by an index constructed following Filmer
and Pritchett (2001) by applying a principal component analysis (PCA) on the following
variables: indicators of whether the household owned a radio, television, refrigerator, tel-
ephone, car, bicycle or motor bike, whether there was electricity in the dwelling and the
quality of the floor material used for the dwelling. In line with Smits and Steendijk
(2015), the outcome of the PCA analysis was translated into a continuous index
ranging from 0 (having none of the assets and lowest floor quality) to 100 (having all
assets and highest floor quality). We could not use the regular DHS wealth index avail-
able in the data set (Rutstein & Johnson, 2004), as it uses information on the quality of
drinking water supply and toilet facilities, which we wanted to study separately in our
analyses.
At the sub-district level (i.e. community level), we included seven contextual variables.
Improved water coverage was measured by the proportion of households with improved
drinking water, i.e. piped water on premises, public taps, tube wells, protected dug well,
protected springs and rainwater collection in the community (UNICEF & WHO, 2015).
Improved sanitation coverage, as a proxy for environmental hygiene, was measured by
the proportion of households with an improved toilet facility in the community. Health
facilities coverage was indicated in line with Monden and Smits (2009) as the proportion
of mothers who gave birth in a proper health facility, such as a hospital, health centre,
village health post or with help of a village midwife. Another health indicator at the com-
munity level was the proportion of children who received three polio vaccinations. The
community level of economic development was indicated by the proportion of households
owning a car. Two context variables – adults’ education and maternal decision power –
were created to measure the availability of (health) knowledge and the strength of the pos-
ition of women in the community. Adult education was measured by the average years of
education completed by adults aged 15 and over in the community. Maternal decision
power was measured by the proportion of mothers who reported that they could decide
by themselves whether a child should be taken for medical treatment. Further description
of variables used in the analysis can be found in the Appendix, Table A1.

Statistical analysis
We used a four level multilevel logistic regression model, with households (level 1) nested
in sub-districts (level 2), nested in districts (level 3), and nested in provinces (level 4).
 GLOBAL PUBLIC HEALTH 1147

Given that the average number of children per household was very small (1.2), children
and households are considered as part of the same level (level 1). The model contains
explanatory variables at levels 1 and 2. Levels 3 and 4 are included as random effects.
The model was estimated with MLWin version V.2.29, using second-order PQL, the rec-
ommended estimation technique for multilevel logistic regression analysis (Goldstein,
2011). Both bivariate and multivariate multilevel models were estimated. Interaction
analysis was used to study how the five main variables (piped water in the dwelling,
point-of-use water treatment, improved toilet, improved water coverage and improved
sanitation coverage) varied across circumstances. Given the explorative nature of the inter-
action analysis, we tested for all potential interactions between the main variables and the
other variables in the model. To be able to focus on the most important interaction effects,
only significant interactions were included in the final model. In this way, a parsimonious
picture is obtained of the way in which the effects of the independent variables differ
between children living under different circumstances. In the interaction analyses,
centred versions of the variables were used. The main effects therefore can be interpreted
as average effects. Statistical significance was evaluated at p < .05 and the coefficients are
presented as odds ratios (OR).

Results
Table 1 presents descriptive of the data. The mothers of 4820 (14.4%) children reported
that they suffered from diarrhoea in the preceding two weeks. Most households have
no access to piped water in their premises (86.82%), treat the water (78.93%) and have
an improved toilet (58.33%). Of the 33,399 children, 16,010 (47.94%) are girls, and
16,925 (50.68%) are from the 2007 DHS data set. The average age of the children is
about two years. About 50% of the households in the community have access to improved
water and 59% to improved sanitation.

Table 1. Descriptive characteristics of children aged under five in Indonesia, DHS, 2007 and 2012.
Variables n/mean %/(SD/range)
Total 33,399 100.00
Children having diarrhoea 4820 14.43
Children with piped water in the dwelling 4402 13.18
Children with point-of-use water treatment 26,361 78.93
Children with improved toilet 19,480 58.33
Gender is girl 16,010 47.94
Mean children age (SD/range) 1.98 (1.42/0–4)
Mean years of mother education (SD/range) 8.67 (3.85/0–15)
Mean household wealth (SD/range) 51.62 (25.94/0–100)
Children living in urban area 14,037 42.03
Children from DHS 2012 16,474 49.32
Context factors
Mean improved water coverage (SD/range) 0.50 (0.29/0–1)
Mean improved sanitation coverage (SD/range) 0.59 (0.30/0–1)
Mean health facilities coverage (SD/range) 0.48 (0.37/0–1)
Mean vaccination coverage (SD/range) 0.65 (0.24/0–1)
Mean economic development (SD/range) 0.07 (0.10/0–1)
Mean adults’ education (SD/range) 7.94 (2.25/0.26–16)
Mean mother’s decision power (SD/range) 0.82 (0.18/0–1)
1148 A. KOMARULZAMAN ET AL.

Table 2. Bivariate multilevel analysis of the diarrhoea prevalence of

children aged under five, Indonesia, 2007 and 2012.
OR (95% CI)
Piped water in the dwelling
No (ref) 1.000
Yes 0.748 [0.655–0.854]*
Point-of-use water treatment
No (ref) 1.000
Yes 1.110 [1.003–1.227]*
Improved toilet
No (ref) 1.000
Yes 0.826 [0.762–0.895]*
Gender
Boy (ref) 1.000
Girl 0.795 [0.740–0.853]*
Child’s age 1.264 [1.159–1.378]*
Child’s age square 0.883 [0.863–0.902]*
Mother’s education 0.979 [0.968–0.989]*
Household wealth 0.844 [0.807–0.883]*
Living in an urban area
Rural (ref) 1.000
Urban 0.870 [0.785–0.966]*
Survey year
2007 (ref) 1.000
2012 1.076 [0.961–1.205]
Context factors
Improved water coverage 0.951 [0.904–1.001]
Improved sanitation coverage 0.830 [0.778–0.875]*
Health facilities coverage 0.816 [0.772–0.863]*
Vaccination coverage 0.865 [0.821–0.911]*
Economic development 0.865 [0.819–0.914]*
Adult education 0.860 [0.814–0.907]*
Mother’s decision power 0.930 [0.884–0.979]*
Note: Ref, reference category.
*p < .05.

The results of the bivariate analysis are presented in Table 2. The figures in this table
show how diarrhoea prevalence varies among households and communities with differ-
ent characteristics. Most of the coefficients are significant and support the hypothesis
that improved water and sanitation reduce the risk of childhood diarrhoea. Households
with piped water or with an improved toilet facility have lower odds of diarrhoea. Inter-
estingly, water treatment is associated with a higher risk of diarrhoea among children.
As expected, girls have a lower risk of having diarrhoea. The significance of age and its
squared term suggests that the relationship between age and the odds of having diarrhoea
is curvilinear with increasing prevalence in the first two years of life and decreasing preva-
lence afterwards. Mother’s education, household wealth and living in an urban area all are
associated with significantly lower odds of having diarrhoea. There is no significant differ-
ence in diarrhoea risk between the two survey years.
Except for improved water coverage, the bivariate model shows that all community
characteristics are significantly associated with diarrhoea prevalence and that the direction
of their effects is in line with our hypotheses. The likelihood that children have diarrhoea is
lower when more households in the community have improved water and sanitation, and
the community is characterised by better health facilities, a wealthier or a better-educated
population, and women with more decision-making power.
 GLOBAL PUBLIC HEALTH 1149

Table 3. Multilevel analysis of the diarrhoea prevalence of children aged under five, Indonesia, 2007
and 2012.
Model 1 – no interaction Model 2 – with interaction
OR (95% CI) OR (95% CI)
Intercept 0.134 [0.115–0.157]* 0.137 [0.117–0.160]*
Piped water in the dwelling 0.797 [0.692–0.918]* 0.763 [0.643–0.907]*
Point-of-use water treatment 1.106 [0.994–1.232] 1.089 [0.977–1.214]
Improved toilet 0.992 [0.899–1.096] 0.951 [0.860–1.052]
Girls 0.791 [0.736–0.850]* 0.793 [0.738–0.852]*
Child’s age 1.265 [1.159–1.379]* 1.276 [1.170–1.392]*
Child’s age square 0.882 [0.863–0.902]* 0.880 [0.861–0.900]*
Mother education 0.994 [0.981–1.006] 0.996 [0.983–1.008]
Household wealth 0.905 [0.853–0.959]* 0.890 [0.839–0.944]*
Living in urban area 1.177 [1.035–1.338]* 1.223 [1.075–1.392]*
Survey year 1.261 [1.119–1.421]* 1.271 [1.128–1.432]*
Context factors
Improved water coverage 1.002 [0.950–1.057] 1.013 [0.958–1.071]
Improved sanitation coverage 0.917 [0.843–0.998]* 0.898 [0.825–0.977]*
Health facilities coverage 0.870 [0.806–0.940]* 0.858 [0.795–0.926]*
Vaccination coverage 0.944 [0.891–1.001] 0.947 [0.893–1.005]
Car ownership 0.947 [0.886–1.012] 1.001 [0.933–1.074]
Adult education 1.074 [0.981–1.174] 1.057 [0.966–1.157]
Mother decision power 0.961 [0.913–1.012] 0.970 [0.921–1.022]
Interaction effects
Piped water in the dwelling × living in urban area 2.142 [1.490–3.078]*
Piped water in the dwelling × health facilities coverage 0.704 [0.588–0.842]*
Piped water in the dwelling × vaccination coverage 1.267 [1.063–1.512]*
Piped water in the dwelling × adult education 0.819 [0.685–0.978]*
Improved toilet × child age 0.906 [0.858–0.958]*
Improved toilet × mother decision power 1.090 [1.005–1.183]*
Improved toilet × improved water coverage 1.102 [1.005–1.207]*
Improved water coverage × car ownership 1.154 [1.080–1.233]*
Improved water coverage × improved sanitation coverage 0.914 [0.860–0.972]*
Improved sanitation coverage × household wealth 0.922 [0.879–0.968]*
Note: Ref, reference category.
*p < .05.

Multivariate analysis
Results of the multivariate analysis are presented in Table 3. Model 1 includes only the
main effects and model 2 includes both the main and interaction effects.
After controlling for other factors, the prevalence of diarrhoea is lower among children
with piped water in the premises (OR = 0.80, 95% CI: 0.69–0.92) and, to our surprise,
higher when the water is treated (OR = 1.11, 95% CI: 0.99–1.23), whereas no significant
effect is found for an improved toilet in the household (OR = 0.99, 95% CI: 0.90–1.10).
At the community level, the odds of having diarrhoea decrease as the coverage of
improved sanitation in the community is higher (OR = 0.92, 95% CI: 0.84–1.00) while
no significant effect of the coverage of improved water on diarrhoea prevalence (OR =
1.00 95% CI: 0.95–1.06) is found.
Children’s age and age-squared are significantly related to diarrhoea risk, with a similar
curvilinear shape as in the bivariate model. Also, the gender difference remains important,
with lower prevalence among girls. At the household level, the effect of wealth remains
significant, with less diarrhoea in wealthier households, but maternal education loses its
significance. At the community level four variables – vaccination coverage, economic
development, adult education and mother’s decision power –lose their significance,
while the other effects remain unchanged.
1150 A. KOMARULZAMAN ET AL.

Interaction effects
To explore how the effects of the five core variables (piped water in the dwelling, water
treatment, improved toilet, improved water coverage at community level and improved
sanitation coverage at community level) vary across contexts, we computed interactions
between these variables and the other factors in the model. These interactions were itera-
tively tested and the significant interaction effects were included in the model. This
explorative procedure produced 10 significant interactions that were included in model
2 of Table 3.
The protective effect of piped water turns out to be stronger for children living in a
community with good health facilities coverage and a more highly educated population
(OR = 0.70, 95% CI: 0.59–0.84 and OR = 0.82, 95% CI: 0.69–0.98, respectively). This stres-
ses the importance of clean water as a basic requirement for good facilities or available
knowledge to be effective. The importance of piped water is further highlighted by the
fact that in rural areas and areas that are badly covered by vaccination campaigns, the
availability of piped water in the dwelling is associated with less diarrhoea. The difference
between urban and rural areas is particularly strong (OR = 2.14, 95% CI: 1.49–3.08).
Further analysis shows that in rural areas the OR is 0.55 (95% CI: 0.42–0.72). Conse-
quently, in rural areas piped water is particularly important, while in urban areas piped
water does not make a significant difference for diarrhoea risk (OR = 1.19, 95% CI:
0.95–1.48).
Improved sanitation at the household level reduces diarrhoea risk for older children
(OR = 0.91, 95% CI: 0.86–0.96). This finding makes sense, given that babies and very
young children do not yet use toilet facilities. The positive interactions of improved sani-
tation with maternal decision power (OR = 1.09, 95% CI: 1.01–1.18) and water coverage at
the community level (OR = 1.10, 95% CI: 1.01–1.21) point towards the existence of com-
pensatory effects, whereby better toilet facilities at the household level may compensate for
lack of women’s power and bad water coverage at the community level. In situations where
women’s power is at its lowest level, the effect of having a better toilet facility in the house
is significantly negative (OR = 0.64, 95% CI: 0.44–0.95), hence associated with less diar-
rhoea. This is also true in communities with bad water coverage (OR = 0.81, 95% CI:
0.66–0.98).
Improved water coverage at the community level is most effective in reducing diarrhoea
risk in less developed areas. It is also more effective if it goes together with better sanitation
coverage at the community level and vice versa (OR = 0.91, 95% CI: 0.86–0.97), so that
improvement of water and sanitation facilities in regions and villages should go hand in
hand.
Finally, we see that the children of the wealthiest households profit most from
improved sanitation at the community level. Although these children experience the
most favourable circumstances at home, their risk of getting diarrhoea remains high as
long as they live and play in a polluted community.

Discussion
The results of the current study indicate that having piped water in the dwellings reduces
the odds of childhood diarrhoea by 24%. This percentage is similar to the 22% reduction in
 GLOBAL PUBLIC HEALTH 1151

diarrhoea risk reported in a meta study (Fewtrell et al., 2005). However, we also find that
piped water is particularly important in rural areas, where the circumstances are more dif-
ficult and hence improvement of water supply can make more of a difference. The fact that
in urban areas the effect of piped water is weaker might have to do with the poor quality of
the piped water system or with fluctuation debit. When the pressure in the pipes is low,
polluted water from outside may enter and reduce the water quality (Shaheed et al.,
2014). Another consequence of this fluctuating debit is that households need to store
the water which again increases microbial (re)contamination that may increase diarrhoea
risks (Wright et al., 2004).
The benefit from high coverage of health facilities complements the protective effect of
piped water in the dwellings on childhood diarrhoea. Meanwhile, this protective effect is
more effective in a community with low vaccination coverage. This indicates the complex-
ity of diarrhoea disease, which can be transmitted not only through water but also through
other routes such as food contamination (Agustina et al., 2013) that cannot be solved
merely by the provision of safe water at the household level.
A surprising finding is that point-of-use water treatment is not significantly associated
with diarrhoea prevalence and that there are no significant interactions with this factor.
This result contrasts with research summarised in Fiebelkorn et al. (2012). It might indi-
cate that in many Indonesian households water treatment is ineffective. This would be in
line with previous studies (Sodha et al., 2011; Vollaard et al., 2004), which find that in
Indonesia a significant proportion of the treated water is (re)contaminated by E. coli
while being stored.
In contrast to previous studies (Fewtrell et al., 2005), the quality of the toilet facility at
the household level has no direct effect, although we found some significant interaction
effects. Having an improved toilet facility is associated with lower diarrhoea prevalence
for older children, and in areas where mothers have less decision power, or improved
water coverage is low. That older children (but still younger than five years) benefit
from an improved toilet seems logical as these children are able to use toilet facilities
independently.
The significance of the main effect of improved sanitation at the community level con-
firms the results presented in Buttenheim (2008). The effect of improved sanitation cover-
age is strengthened in communities with improved water coverage, which indicates that
improvement of water and sanitation should go hand in hand to get the best results.
This is consistent with the result reported by Hughes and Dunleavy (2000, as cited in
Alderman et al., 2003) who found joint externality effects of community access to water
and sanitation in rural India, while their direct effect was not detected.
In sum, the fact that we found 10 significant interaction terms illustrates the importance
of studying the circumstances under which particular measures (piped water, better sani-
tation) are effective in reducing children’s odds for getting diarrhoea. A limitation of this
study is the use of a cross sectional design, which reduces the possibility to determine
causal relationships. Lastly, this study focuses on Indonesia only, which could limit the
applicability to other countries. However, the current study complements previous
studies (Fuller, Clasen, Heijnen, & Eisenberg, 2014; Fuller, Westphal, Kenney, & Eisen-
berg, 2015), which document variation in the effect of water and sanitation on childhood
diarrhoea between countries, by showing this variation between sub-districts in one
country.
1152 A. KOMARULZAMAN ET AL.

Conclusion
Diarrhoea is an important health issue in Indonesia as well as in many other developing
countries. This study finds that piped water in the dwelling reduces diarrhoea risk for
young children, whereas point-of-use water treatment and improved toilet appear to
have no significant direct influence. This suggests that treatment is not done effectively
and that it might be good that the government starts campaigns to make the public
aware of this.
We hypothesised that the protective effect of water and sanitation facilities would be
higher in poor situations. This appeared to be not always the case. We indeed found
piped water at the household level to be particularly important in rural areas. However,
the positive effect of better sanitation at the community level turned out to be stronger
in communities with better water quality. This last finding illustrates the importance of
improving drinking water and sanitation simultaneously and at the community level
instead of some households only.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by a scholarship from the Directorate General of Higher Education
(DIKTI), Ministry of Education and Culture, Republic of Indonesia.

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Appendix

Table A1. Description of variables used in the analysis.

Variable Description
Child level variable
Diarrhoea incidence Equal to 1 if child suffered from diarrhoea in the past two weeks, 0 otherwise.
Gender Equal to 1 if child was girl, 0 otherwise.
Child’s age Child’s age in years (0–4).
Household level variable
Piped water in the Equal to 1 if household had access to piped water in the dwelling, 0 otherwise.
dwelling
Point-of-use water Equal to 1 if household treated the water before consumption by boiling, bleaching,
treatment chlorinating, filtering or solar disinfection, 0 otherwise.

(Continued )
 GLOBAL PUBLIC HEALTH 1155

Table A1. Continued.

Variable Description
Improved toilet Equal to 1 if household had private toilet with septic tank, pit latrine or composting toilet, 0
otherwise.
Mother’s education Number of years of schooling completed by mother
Household wealth Continuous variable of household’s assets (1–100)
Living in an urban area Equal to 1 if household lived in urban area, 0 otherwise.
Survey year Equal to 1 if the year of DHS survey is 2012, 0 otherwise.
Community level variable
Improved water coverage Proportion of households in the community with access to improved water sources (piped
water on premises, public taps, tube wells, protected dug wells, protected springs and
rainwater collections).
Improved sanitation Proportion of households in the community with access to improved sanitation facilities
coverage (toilet with septic tank, pit latrine, or composting toilet)
Health facilities coverage Proportion of mothers in the community who gave birth in a proper health facility (hospital,
health centre, village health post, or with help of a village midwife).
Vaccination coverage Proportion of children in the community who received three polio vaccinations.
Economic development Proportion of households in the community owning a car.
Adult education Average years of education completed by adults aged 15 and over in the community.
Mother’s decision power Proportion of mothers in community who reported that they could decide by themselves
whether a child should be taken for medical treatment.